Integrated Neighbourhood Teams (INTs) – How to create the conditions where INTs can flourish

In this second blog in our series about the journey to neighbourhood health our Medical Director, Dr Natasha Curran talks to Dr Minal Bakhai, Director of Primary Care and Community Transformation at NHS England and a GP in North West London, about what is needed in general practice to enable effective neighbourhood health teams to flourish. This couldn’t be more relevant following NHS England’s publication of the 2025/26 operational planning guidance which included guidance on neighbourhood health.

Building strong foundations – stability & skills

For integrated neighbourhood services to develop, they need to grow on strong foundations – moving away from firefighting and a model of reactive care to a more proactive, holistic, biopsychosocial model. To do this, we need to embed a strategy that enables us to make full use of our workforce, innovation and technology; building the skills, capabilities, operational and digital maturity, and creating the time and headspace required to genuinely work as integrated teams and partner with people and communities.

Modern General Practice is a core component of the journey towards neighbourhood health. It has sustainability at its heart, helping build strong foundations to enable general practice to play a key role in the development of neighbourhood working. Building integrated teams is a complex change – it is significantly relational - and building trust, a shared purpose, community connections and embedding new ways of working takes time, capacity and changes in culture. We need to develop improvement capabilities where primary and community services have historically often not had the opportunities and protected time to do so.

The General Practice Improvement Programme builds evidence-based content for embedding Modern General Practice and codifies it into practical hands-on support. It assists practices and PCNs to make improvements rigorously and realise benefits quickly and reliably. Additionally, it takes an agile approach, actively generating and incorporating evidence and learning from practices, and helping others utilise and adapt this for their own context in a manageable and sustainable way. The programme has provided hands-on support to over 1500 practices to do just this.

We need to be better at talking to each other

Transformation requires alignment at multiple levels of the organisation. The national Primary Care and Community Transformation team has brought ICBs from across the country together to understand and describe what good looks like in terms of enabling transformation in primary care. It also describes the importance of creating the space to share and learn from all the great work that's happening across each system. As part of this approach, it has co-produced with systems a shared view of the key capabilities needed to create the right conditions for effective change, so systems can systematically understand their strengths and identify areas for improvement. Through this forum, we can start identifying development needs and solutions to some of the barriers to transformation, connecting people/organisations to have more in-depth conversations about what they’ve done and what adds the most value.

Local leadership and peer-to-peer support are critical for improvement to spread. The National Primary Care Transformation Peer Ambassador Academy launched in 2024. This academy brought together a peer-to-peer network of 100 frontline staff (e.g., GPs, nurses and managers) from all 42 ICSs in England. Those who attended have led complex change locally and can authentically share their own experience to inspire, spread learning and support others.

The ambassadors are sponsored by their local system and share the work they've done, both across the national peer network and locally. The academy builds a distributed cadre of primary care transformation leadership and a learning system to spread tested improvements. The fact that this programme was vastly oversubscribed is a sure sign of system pull.

Being evidence-based and outcomes-focused

The programme has used different metrics to measure improvements, e.g. patient access, continuity of care, capacity optimisation, patient experience and staff experience – reducing avoidable appointments and releasing staff time to focus on where it’s most needed.

Understanding need is key for realising outcomes. Using structured information gathering, population health segmentation and risk stratification data, you can understand why people are presenting, the acuity of their immediate presenting complaint, and the complexity of their broader needs. By utilising this information at the point of contact, you can better navigate a patient to the right service, ensuring they receive timely care in the best place. This might be via a neighbourhood team for those where multiprofessional, community support and co-delivery are required and, prioritising continuity of care for those who need it most.

Modern General Practice is underpinned by an evidence-based approach. The Primary Care and Community Transformation team has been working with the Health Foundation’s Improvement Analytics Unit to support them with technical analytics, tools, models and methods to evaluate, peer review and publish research on the impact of Modern General Practice. This results in transparent knowledge sharing by building a learning health system. It also permits an equity focus on improvement. Additionally, they have carried out significant user research with practices and those digitally less confident to improve the quality of practice websites and digital tools to ensure they are highly usable and accessible.

A recent study showed that combining well-designed digital tools with inclusive implementation (through Modern General Practice) has helped reduce inequalities in patient experience of access, disproportionately benefiting those who, traditionally, have been most marginalised. This work is vital because we can do great things in transformation and improvement, but if we do not evaluate in terms of equity, we might miss some crucial unintended consequences.

Whilst we absolutely recognise that every neighbourhood team will use a range of different success measures because of its context and population focus, we agree that some consistency in the outcomes for integrated neighbourhood working will help us to be clear about the case for change and understand what adds most value, what doesn’t, and why.

How can Health Innovation Networks (HINs) help?

Many HINs have specialist expertise that does not traditionally sit within NHS structures, however, that expertise is too often felt to be siloed away from frontline staff and the operational context. We wondered what it would be like to see HINs more integrated at a neighbourhood (sometimes called “place” or community/locality) level, potentially providing some support to neighbourhood services and primary and community teams. This would help to bring in specialist skills and resources in service design, change management, benefits realisation and evaluation as part of a multiprofessional team. Building a deeper partnership approach could enable a greater understanding of the problems on the ground and also result in HINs’ better demand signalling to industry partners.

Overseeing so much transformation nationally and experiencing it herself in her practice, Minal has learnt that bringing together an understanding of the clinical, the operational, the user needs, the service design, the data, the digital, and improvement in a closely knit team can drive change on the ground.

How might HINs work more closely with the primary care transformation peer ambassadors and communities? How might they support building the skills and capabilities needed to embed successful transformation? What areas would we focus on to derive the most value? If you have embarked on this already or have thoughts about what we could/should do more jointly, locally, or nationally, please do get in touch.

What's next?

In our next blog, we will be looking at how HINs are supporting neighbourhood teams via the evaluation of some of their services.